Mental Health

Schizophrenia Spectrum and Other Psychotic Disorders

Overview

In DSM 5, this family of diagnoses includes schizophrenia, brief psychotic disorder, schizophreniform disorder, schizoaffective disorder, substance/ medication-induced psychotic disorder, and psychotic disorders due to another medical condition, and schizotypal personality disorder.

This spectrum of disorders is characterized by abnormalities in the following domains:

1. Delusions: These are fixed beliefs which do not change despite conflicting evidence. Delusional ideas may have persecutory, referential, somatic, religious, and grandiose themes. They may or may not have bizarre content.
2. Hallucinations: These phenomena appear to the patient to be genuine perceptions, but have no external stimulus. Like genuine perceptions, they appear vivid. Auditory hallucinations are most common, but hallucinations may occur in any sensory modality. An example is hearing “voices” which are experienced as distinct from the patient’s thoughts.
3. Disorganized thought: This is normally inferred from patient speech. There may be looseness of association, tangentiality, and/or incoherence.
4. Grossly disorganized or abnormal motor behavior.
5. Negative symptoms including diminished emotional expression (speech, eye contact, “body language”); avolition (reduced self-motivated purposeful action), alogia (reduced speech output), anhedonia (loss of ability to experience pleasure) and asociality (apparent lack of interest in social interactions.)

Current abnormalities in these domains are disqualifying for law enforcement work.

Delusional Disorder

The essential diagnostic feature of this disorder is one or more delusions lasting more than 1 month. A delusion is a fixed false belief which does not change despite conflicting evidence. Delusional ideas may have persecutory, referential, somatic, religious, and grandiose themes. They may have bizarre content (criterion A); not meet criterion A for schizophrenia (i.e., does not have an abnormality in any of the other 5 domains of function listed above) Finally, apart from the impact of the delusion, functioning is not impaired and the person tends to appear normal to others.

There is a 0.2% lifetime prevalence without gender differences in frequency. Several types of delusional disorder are recognized, based on the focus of the delusions:

When not focused on the delusion(s) persons with delusional disorder appear normal to others in their personal appearance and behavior. However, when focused on their delusions difficulties with others may arise. Violence may occur, in particular with jealous, erotomanic, and persecutory types. The condition is typically stable, with a small proportion going on to develop schizophrenia.

Brief Psychotic Disorder and Schizophreniform Disorder

Both conditions will present with a psychotic episode. These disorders differ from Schizophrenia in terms of the duration of the episode. In the case of brief psychotic episode psychotic symptoms may last 1-30 days, but not longer. In schizophreniform disorder, the duration, may be 1-6 months, but not longer. Once these conditions have resolved, the long-term prognosis may be good. However, one cannot prospectively distinguish between a brief psychotic episode or schizophreniform disorder and schizophrenia in a period of remission. A period of observation, and medication management over time is required to clarify the diagnosis.

Substance/Medication-Induced Psychotic Disorder

Patients in this diagnostic category exhibit psychosis, but the symptoms can be shown to develop during or soon after substance intoxication or with-drawal, or after exposure to a medication. Additionally, the implicated sub-stance or medication is known to be capable of inducing these symptoms. Causal agents include amphetamines, cocaine, steroids, sedatives, hypnotics, anxiolytics, and others. Once the precipitant is identified and eliminated or controlled, return to duty may be considered per the recommendation in the guidance.

Psychotic Disorders Due to Another Medical Condition

Patients in this diagnostic category experience mood changes similar to those of patients with other anxiety disorders, but there is evidence from history, physical examination, or laboratory testing that the disturbance is the direct pathophysiological consequence of another medical condition.

This diagnosis should only be made when:

• A clear temporal association is present between the anxiety symptoms and onset, exacerbation, or remission of the medical condition and psychotic symptoms.
• Features atypical of a primary psychotic disorder are present, e.g., unusual age of onset or course.
• Evidence in the literature exists to support that a known physiologic mechanism causes psychosis.
• Condition is not better explained by a primary schizophrenia spectrum disorder or another mental health disorder.

Diagnostic clarity is essential for the police physician in considering work-ability of the officer or candidate. If the precipitating condition is recurrent or chronic, the associated medical condition must be controlled to an extent that eliminates all psychotic symptoms before return to unrestricted work is considered. Prognosis is also important. The risk of recurrence of psychotic symptoms must be negligible (not higher than that in the general population.)